A calming presence

Called to the scene of a fire, Michael Dubi immediately noticed the elderly woman. She stood in place, silently, simply watching as her home and all of her belongings were consumed in flames directly in front of her.

“She could not speak or move,” says Dubi, president of the International Association of Trauma Professionals (IATP) and an associate professor in the School of Behavioral Sciences at Argosy University, Sarasota. “I held her hands and squeezed them gently and alternatively” — a technique known as bilateral stimulation — “until she calmed down and was able to make eye contact and speak to me and cry. We were then able to contact her children, who came to care for her.”

Across the nation and the world, crises happen every day. Some make headlines, such as large-scale natural disasters like the earthquake that devastated Japan this past year or human-caused atrocities like 9/11. But most fly below the national news radar — local fires, floods and car accidents that are smaller in scope but no less devastating to those who feel their impact firsthand.
Counselors who haven’t been trained in traumatology might assume that their role in the immediate aftermath of a disaster or crisis is no different than their traditional counseling role — to provide therapy, Dubi says. That would be a mistake. “You can’t do therapy with someone who’s just been traumatized,” says Dubi, a member of the American Counseling Association who also runs a private practice in Sarasota. “Therapy is [only] part of the process, and it’s not the first part.”

Jane Webber, an associate professor and coordinator of the counseling program at New Jersey City University, echoes Dubi. “Traditional counseling focuses on setting goals and providing interventions for clients for change,” says Webber, a major contributor to the first edition of Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, published by the ACA Foundation in 2002, and co-editor of the second and third editions, the latter of which was published in 2010. “Disaster mental health counseling is an ecological and solution-focused approach that does not serve to change what is working. It draws on the strengths of individuals and collectively in the community to regroup and return to normal functioning. This is a practical, common-sense approach that is interconnected with the community support. ‘Neighbor helping neighbor’ may be the most effective approach to disaster recovery. Further disaster and crisis counseling serves to prevent the development of PTSD [posttraumatic stress disorder] through safety, stabilization, self-care and coping skills.”

Dubi says the importance of counselors being trained in disaster mental health and traumatology techniques is demonstrated in the sheer number of people who have been or will be traumatized during the course of their lives. He points to research that has shown that the majority of people counselors see have been traumatized. Whether that number is 99 percent or 51 percent of clients, Dubi says, it’s crucial that counselors are fully equipped to help them.

In a world transformed in recent years both by terrorism and a seeming deluge of high-profile natural disasters, it is especially vital that counselors demonstrate the ability to respond in situations of crisis and disaster, Webber says. “In this new normal in a post-9/11 world, it is important for all professional counselors to understand the role of disaster and trauma in people’s lives and to be able to work effectively with clients who have experienced traumatic events,” she says. “Disaster response and crisis counseling are essential areas of knowledge and skill for counselors in the 21st century.”

Creating safety in the midst of chaos

Whether man-made or natural, disasters are terrifying, life-threatening events, says Webber, a member of ACA. “Both types of traumatizing events can destroy our sense of the world as safe and predictable,” she says. “Human-caused mass disasters such as terrorist bombings leave survivors traumatized and vulnerable, propelling us to question our fundamental belief in a safe world.” Among survivors of terrorism, Webber says, feelings of sadness and grief are often intertwined with anger, hatred and revenge. “When others destroy our safety, there is something dreadfully fearful that disrupts our inner core. Before healing can occur, counselors must help survivors restore a sense of safety and security and control over their lives.”

“After natural disasters such as hurricanes or floods,” she continues, “grief, sadness and shock are mixed with resignation and resolve to return to normal, to rebuild homes and neighborhoods, and to restore connections among families and friends. The emphasis is different, and the resolve of the survivors may focus more on recovery without the fear of terrorism.”

Since 9/11, Webber says, the counseling profession has become more knowledgeable about how people respond to disaster and traumatic events. “There is a greater understanding of the stages of recovery in the immediate aftermath of a disaster and our role in responding in each stage,” she says. “We understand that most disaster survivors are normal people who are responding to an abnormal event, and we avoid pathologizing or viewing people as sick because of their response to the event.”

Counselors also now recognize that most survivors of mass disasters will return to normal functioning within a few days or weeks without mental health treatment, Webber says. The majority of survivors will not develop PTSD, she adds, and not everyone exposed to a traumatic event will show distress or become traumatized. “Actively involving and empowering survivors during the first days and weeks after the event speeds the return to normalcy,” Webber says. “We know that many people experience psychological growth after experiencing traumatic events, and this awareness transforms our understanding of the power of trauma.”

Webber points to Judith Herman’s triphasic model of trauma recovery as a guide for counselors. “[The elements] are safety and stabilization, remembering and mourning, and reconnecting and healing. In the immediate aftermath of a disaster, providing a safe and secure place, physically and emotionally, is paramount.”

Dubi agrees, stressing that the first priority for counselors responding in a disaster or crisis is to help survivors regain a sense of safety. He contends the next most powerful intervention is helping clients with basic needs such as finding a place to sleep, calling their loved ones and similar tasks. “People who are trained in disaster work know enough not to do therapy at the disaster site,” he says. “You don’t do that — [you] get the people what they need right now.” The goal is to try to resolve the day-to-day issues that have been disrupted, Dubi says, and to help clients as much as possible in reestablishing a sense of safety, normalcy and predictability.

Cecile Brennan, an ACA member and coordinator of the counseling program at John Carroll University in University Heights, Ohio, often tells her students that in a disaster situation, a traditional counseling response isn’t the right one. And there’s a good reason for that. “A person [in a disaster or crisis situation] does not have the sort of mental state to really be reflecting on their emotional state — they’re in a response mode,” Brennan says. “So to ask the kinds of probing, open-ended questions that you might ask in traditional counseling is just not appropriate. They’re in a kind of survival mode, and you don’t want to undermine that process. It may be important for someone working through a crisis not to be feeling things intensely. And we don’t want to undermine that defense mechanism.” The best thing counselors can do for individuals in a disaster or crisis situation is to make sure they’re safe, be supportive and simply listen, she says.

Roxane Dufrene, an associate professor in the counselor education program at the University of New Orleans, has worked with survivors of 9/11 as well as individuals who lived through Hurricane Katrina. She agrees that competently working with survivors of disasters or crises means helping them find ways to meet their basic needs, while also listening with empathy. Dufrene points out that the purpose of crisis intervention work is to stabilize people and return them to where they were before the crisis — not further beyond that.

The hard part for counselors is overcoming the desire to fix the situation or make it better for clients, says Dufrene, a member of ACA. The reality is that counselors can’t fix it, she says, and they certainly should never tell clients that everything is going to be all right.

Helping clients cope

Psychological first aid (PFA) is now considered the accepted evidence-informed practice for postdisaster assistance, Webber says. PFA provides scripts for responders, and from this approach, counselors learn to provide safety, reduce distress, restore stabilization and promote coping skills, she explains. “Like medical first aid, psychological first aid reduces immediate distress as well as the potential for long-term psychological problems such as PTSD,” she says. “Psychological first aid builds upon the individual’s coping skills and social support systems to enhance resiliency and recovery.”

The eight core actions of PFA are contact and engagement; safety and comfort; stabilization; information gathering about current needs and concerns; practical assistance; connection with social supports; information on coping; and linkage with collaborative services. The core actions are not meant to be followed in a set sequence, Webber says. Instead, the order of action should be determined based on the needs of the survivors.

According to Webber, among the most helpful PFA techniques in the aftermath of a crisis are diaphragmatic breathing, relaxation, containment, tapping, anchoring to a safe place, entrainment and grounding. Entrainment involves using your behavior to calm stressed individuals. “This process helps agitated or distressed individuals who are speaking very loudly or rapidly to slowly calm themselves,” Webber says. “I adapt the volume, tone and pace of my voice to be in sync with the individual’s. I then influence the individual’s next response to resonate more with me and to be a little softer or slower.”

“Grounding helps individuals reorient themselves and reduce emotional distress when they appear to be losing touch with their environment, especially in the chaos of moving to a point of distribution or a family center immediately after a traumatic event,” Webber says. “Grounding helps them turn their attention back to the outside world by looking for and naming nondistressing objects that they can see, hear or feel, such as the table, the fans oscillating, [a] blanket, while they breathe slowly.”

STOP and SOLER are two acronyms for crisis intervention strategies that help the responder and the survivor connect, Webber says. STOP stands for Sit, Think, Observe and Plan. This reminds counselors to thoughtfully plan their responses and not to act impulsively, she says. SOLER stands for Sit or Stand Squarely, with Open posture, Lean forward, make Eye contact and Relax.

When working with a client at a disaster site, Webber makes sure her first contact is nonintrusive and respectful, understanding that the person might not want her help at that moment.

She offers an example of how she might approach a client using and adapting PFA scripts: “Hi, I’m Jane, and I’m part of the county volunteer team. I’m checking in with you to see how you are doing and to see if I can help in any way. Is it all right if we talk for a few minutes? Can I ask your name? Can I call you Yolanda, or do you prefer Mrs. Jackson? Before we sit and talk, is there anything you need right now, Mrs. Jackson? Water? Juice? Have you had a chance to eat since you arrived here? Good. Let’s sit for a few minutes and talk.”

“This script is calming and supportive,” Webber says. “My plan would also include current information that they want. ‘Here’s what’s going to happen next. You and your children are going together soon to a shelter with cots, blankets, food and clothing. Stay close by, and I will let you know when it’s time to go. Do you have any questions now?’ I may begin by walking slowly in the direction of assistance or to chairs, encouraging the person to follow and sit down with me. It is important for me to think out and plan my response with cultural respect and sensitivity, guiding my level of eye contact, touch and personal space by cultural norms.”

Cultural sensitivity is a central element in working with survivors of a disaster or crisis, Webber says. She offers some advice along those lines to her fellow counselors: Avoid generalizations and stereotypes; adapt disaster response models to the cultural, familial, linguistic, political and community context; understand cultural factors that figure into risk, resilience, coping and PTSD diagnosis; and recognize cultural and spiritual distinctions in grief, suffering and mourning.

Preparing for the future

Counselors will generally work in two- or three-week rotations at a disaster site, which means their assistance to survivors is short term. That makes connecting clients to long-term support a key function. Often, Brennan says, the full emotional impact of the disaster or crisis won’t register with survivors until a few months after the fact, so it’s important to provide them with information about where they can go locally to talk with someone if they need help down the road. She says it’s also helpful to prepare survivors for this possibility by telling them that recovering from what they’ve experienced will be a bit of a journey and that people sometimes need assistance along the way.

To effectively set up clients with support, Dufrene says counselors must familiarize themselves with the systems they are working in, whether that means the responding organization such as the American Red Cross or the community and cultural systems of the clients. Truly understanding those systems will allow counselors to better connect survivors with available resources and support, she says.

Once the immediate aftermath of a crisis or disaster has passed, the hope is that basic safety will be secured and a sense of normalcy will return. At that point, or even further down the road, survivors might seek out counselors for more traditional therapeutic assistance. Dubi points to cognitive behavior therapy (CBT) as one method of assisting clients. The idea behind CBT, he says, is that what people tell themselves and how they think in turn affects how they feel. “CBT can help identify the negative distorted beliefs and their causes,” he says. “It can then extinguish the negative beliefs and help create new, more adaptive beliefs.”

Neurobiological approaches using eye-movement desensitization and reprocessing (EMDR) and Brainspotting, as well as evidence-based trauma approaches such as emotion-focused trauma therapy, can also be helpful to clients, Webber says. Each approach requires that counselors have training, supervised practice and protocols in place, she emphasizes.

Dubi describes EMDR as a type of exposure technique that helps to desensitize a person or alter how he or she reacts to the traumatic memory. With training, a counselor can guide the client in bringing up the memory, and through repeated bilateral stimulations, the client slowly desensitizes, reducing the level of stress when recalling the memory.

When people go through a crisis, they often operate on autopilot and fail to process their feelings, Brennan says. As time passes, clients might need to tell their story repeatedly until they can fully absorb it into their psyches. With children and some adults, it can be helpful to have them draw what they saw as another way to access those memories, she says.

Webber says counselors still need to broaden their research base to determine which techniques work best. She acknowledges, however, the difficulty in studying the effectiveness of techniques in a relatively uncontrolled and at times chaotic work environment. It can be equally hard to follow up on the effectiveness of techniques after individuals and families have left the disaster area or shelter.

Caring for kids

Attending to children and adolescents who have endured a disaster or crisis requires a unique perspective, says Gail Roaten, an assistant professor and coordinator of the school counseling program at Texas State University. Children who survive a crisis are unquestionably affected, but Roaten says new research is indicating that kids who simply observe a crisis, whether in person or on television, internalize more than was previously thought.

The reaction to a crisis might appear different with each individual child, Roaten emphasizes, but general reactions among children can include seeming confused or numb, feeling helpless or hopeless, feeling afraid for their safety, seeming in a fog, seeking to retell the story of the experience, acting out, experiencing headaches or stomachaches, and fearing a recurrence of the event. Many of the same symptoms will show with adolescents, Roaten says, although they may also feel embarrassed by these fears and try to mask them and pretend everything is fine.

In the early stages after a crisis or disaster, it is paramount to provide kids with a sense of safety and to meet their basic needs, says Roaten, who is a member of ACA. After that, debriefing groups can sometimes be beneficial, she says, allowing the kids a chance to process what happened and talk about the facts. Debriefing also gives counselors a built-in opportunity to inform kids that what they’re feeling is normal. It’s important that counselors talk about what happened in a developmentally appropriate way but without sugarcoating it or avoiding it, Roaten says. If no one talks about the crisis or offers an explanation, children sometimes come up with far-fetched ideas and might even assume personal responsibility for whatever occurred,
she says.

Helping young children cope with crisis sometimes requires techniques other than talking, Roaten says, because these clients won’t necessarily have the words to accurately convey their feelings. Sand tray therapy, play therapy and art therapy are among the effective options for helping kids work through their experiences, she says. She adds that play therapy supports children in developing new neural pathways, helping their brains to heal. “A lot of kids and adolescents will react emotionally out of the amygdala,” Roaten says. “Through play, sand tray and art, children work through emotions while the brain processes the trauma through the prefrontal cortex.”

CBT techniques are also useful with older children and adolescents because they encourage kids to first identify the negative thoughts and beliefs and then reframe them, Roaten says. With adolescents, it can sometimes be beneficial to teach breathing and relaxation techniques and then try some exposure therapy, she says.

Family education is also helpful when children and adolescents are involved in a crisis, Roaten says. Counselors can assist the family in understanding how the kids are feeling and how the rest of the family can offer support. This also allows counselors to provide the family with resources for the future.

Even if children and adolescents have only watched a crisis unfold on television, Roaten says it is still important to talk with them about what happened. For example, a school counselor might do some basic work with students on identifying their own coping skills and processing what they might do in a similar crisis situation.

The most important thing to keep in mind, Roaten says, is that children aren’t adults and shouldn’t be treated as such following a crisis. Counselors should validate children’s feelings concerning the crisis or disaster and then help them process those feelings, she says. Roaten also warns against telling children everything is going to be OK. “You don’t want to offer false assurances,” she says. “We tend to do that more with kids than [with] adults.”

Don’t attempt to do therapy with people who have been traumatized unless they request the therapy or unless they have been sent to you for therapy through a formal referral process, Dubi says.

Don’t speculate or offer inaccurate information, Dufrene says. For example, survivors in a shelter might ask when supplies will be coming. Dufrene says counselors should respond only with information that they’re certain of and tell survivors they will give them additional details as soon as they hear something definitive.

Do remain sensitive to issues of diversity, Dufrene says.Don’t ignore the potential that survivors have for positive experiences and personal growth, Webber says.

Being diligent about self-care

Another piece of advice from these experts is that counselors can’t afford to forget about their own well-being, even in the midst of helping others in a crisis or disaster situation. “Training for disaster and trauma work requires counselor self-care and self-regulation because of the impact of vicarious traumatization and compassion fatigue,” Webber says. “Working in disaster response requires balancing self-care and other care in field situations where practicing self-care techniques may be very difficult.”

Self-care takes on even more importance when counselors find themselves in the dual role of being both a caregiver and a survivor who has been touched personally by a traumatic event in his or her community, Webber says. “In New Orleans [with Hurricane Katrina] and at Virginia Tech [with the mass shootings], counselors were not only experiencing the impact of their clients’ trauma, but they were also personally affected by the traumatic event,” she says. “In their community, who takes care of the caregiver when all the caregivers are responding to the needs of others? This concurrent or dual traumatization may dramatically increase the impact on the counselor.”

Among Webber’s recommended self-care activities:

Identify and rely on your peer-support family.

List a menu of relaxing activities on an index card so you can refer to it whenever you need an idea of a quick way to reduce your own stress.

Make a list of the triggers that affect you so you can recognize them and plan ways to reduce their sensory impact.

Commit to regular physical exercise even when working in the field.

Monitor self-awareness of somatic stressors.

Practice diaphragmatic breathing.

Take time to journal.

Webber says counselors who are both caregivers and survivors can be pulled between dealing with their own emotional reactions and helping others. A good first step, she says, is for counselors to talk with their partners or field supervisors. They also need to work under supervision in the field, guard against overworking and consider taking a step back from the caring function so they can rest temporarily and recover.

Self-care is key to prevention of the negative symptoms of secondary traumatic stress, Dubi says. “These symptoms often resemble PTSD, and they present a real risk to trauma workers who are exposed, over and over, to the horrible stories of their clients’ traumatic experiences. Self-care should be part of a balanced life that includes personal counseling, exercise, engaging in activities that are not related to work, teaching friends and colleagues to be supportive [and] developing spirituality, whether it is religious, meditative, tai chi, journaling or anything that is self-soothing.”

Being prepared

Experts in disaster mental health and crisis counseling emphasize that training is a must, not just for counselors who plan to work in disaster and crisis situations, but for all counselors. “Most individuals will experience traumatic events in their lives,” Webber says. “Thus, every counselor must be ready to provide trauma-informed counseling and, in the event of a mass disaster, know the basics of disaster response.”

Thanks to new standards in 2009, graduates of counseling programs accredited by the Council for Accreditation of Counseling and Related Educational Programs now leave school equipped with the knowledge, understanding and skills needed to respond to disasters, crises and trauma-causing events, Webber says. For counselors who don’t possess that training or would like to acquire additional training, Dubi points to offerings by IATP as well as the American Red Cross trainings available at each ACA Annual Conference. PESI Healthcare and Cross Country Education also offer seminars and continuing education credits, he says.

Statewide training initiatives provide another opportunity. For example, Webber says, New Jersey provides free training to become certified as a disaster response crisis counselor. The National Child Traumatic Stress Network is an additional venue for training, Webber says, focusing on traumatized children, adolescents, their families and communities.

All counselors should have some training in the area of crisis and disaster work, even if they don’t plan to specialize in it, Brennan says. “Crisis and disaster are part of ordinary life. If you counsel any number of people, you’re going to bump up against this. It’s just being well prepared,” she says.

Dubi echoes Brennan’s sentiment. “Every counselor who works with people is responding to crises or disasters,” he says. “Overwhelmingly, the clients that come in have been abused, have been traumatized, whether we like it or not. Most of the disorders my clients come in with are traumagenic. So, yes, every counselor needs to be trained in it, and no counselor who practices with human beings is going to escape it.”

Counselors who want to help out in their own backyards in the event of a crisis or disaster might consider seeking out their local Community Emergency Response Team (CERT), says Cecile Brennan, coordinator of the counseling program at John Carroll University.

Brennan, who volunteers with a CERT, says the focus of these groups is to train citizens in local communities to be able to respond in a disaster before first responders are able to arrive or in case they struggle to meet the demand, whether due to the widespread nature of the crisis, communication failures or other factors. For example, Brennan says, if your neighborhood were to get flooded and first responders couldn’t arrive immediately, members of the CERT could manage until the responders were able to get through.

When counselors are part of a CERT, Brennan says the team benefits from an added mental health perspective and a level of psychological expertise. By participating in a CERT, counselors can raise awareness of how to properly manage emotional responses of individuals involved in a disaster.

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I am a grad student with Walden University online. My major is mental health counseling with a specialization in crisis and trauma. I am really interested in becoming involved with CERT. I live in Northwest Georgia, any idea who I should contact?